Save time and money!
P.O. Box 22-9080, Hollywood, FL 33022-9080
Save time and money! Make your payments electronically. No more hand written checks, no more late fees. Direct debit your account with an electronic funds transfer (EFT)! To apply, follow these easy steps: 1. Complete this form with your name, policy number, bank information and signature. 2. Enclose a blank check from your current checking account and mark this check “VOID” or provide our savings account or credit card information. 3. Mail to the address indicated above of fax to 1-800-682-0817. 4. PLEASE, do not return the form with your payment.
Direct Debit Authorization Agreement In this Agreement, the term “Company” shall mean Bristol West Insurance Company (in AL, AR, CO, FL, GA, ID, IA, IL, IN, KS, KY, ME, MI, MO, MT, ND, NE, NH, OK, PA, SC, SD, UT, VA and WI), Bristol West Casualty Insurance Company (in OH, MN, VA and WY), Bristol West Preferred Insurance Company (in MI), Coast National Insurance Company (in AZ, CA, GA, MS, NV, OR, PA, TN and WA), or Security National Insurance Company (in FL), Home State County Mutual Insurance Company (in TX) or Bristol West Specialty Insurance Company (in TX). Please refer to your Declarations page to determine which entity pertains to you. By signing below, I hereby agree to the terms and conditions of this authorization agreement as follows: As the Named Insured, I hereby authorize the Company to electronically deduct monthly installments for payment of my insurance policy premiums, subsequent renewal down payment and monthly installments, and to initiate credit entries in the event of erroneous charges. I hereby authorize the Financial Institution indicated below to accept and post these transactions to my account, shown below.
This authorization will remain in effect until I provide written notice to the Company of its termination. I understand that, in the event I decide to terminate this payment method, I must advise the Company at least 3 business days prior to the installment due date. In the event that I do terminate it, I understand that I continue to be obligated to make the current payment due as outlined on the payment schedule, and my bill plan and premium may change, requiring a larger down payment and different installment payments.
I authorize the Company to adjust said transactions to reflect any premium changes and policy renewals. The Company agrees to notify me, at least 10 days in advance, in the event that the electronic transaction will be greater than the previous electronic transaction.
In the event that this enrollment occurs after the inception of the policy, we will debit your account the amount reflected on your current invoice, as long as we receive the authorization form at least 3 business days prior to the current due date.
In the event that my Financial Institution or account number changes, I acknowledge that 3 business days advance notice must be given to the Company before the changes take effect. I understand that I will be receiving a payment schedule shortly with the due dates, amounts of future withdrawals, and applicable fees. Upon receipt, I will retain the payment schedule for future reference since the Company will not send out monthly notifications.
I understand and agree that an installment fee will be charged and deducted with each monthly installment payment. I further understand that if my financial institution does not honor any payment, an NSF fee will be assessed to the balance due on my policy. For the specific amount of each fee, please contact your producer or call the Company at 1-888-888-0080. In addition, these fees will be reflected on the payment schedule that will be sent to you after the Company processes this request.
To ensure accuracy, if using a checking account, please attach a sample check and mark it as VOID. Customers of credit unions should verify their account numbers as some credit unions use different account numbers than the numbers printed on checks.
Required information for all payment types, please print clearly: Insured Name:_____________________________________
Date: _____________________________________
Policy Number: ____________________________________
Phone #: __________________________________
Complete the following for checking and savings:
Complete the following for credit/debit card:
Select account type ( ) Checking or ( ) Savings
Select account type: ( ) MC ( ) Visa ( ) Discover
Bank Name:_____________________________________ Name on Account: _______________________________
Name on card: __________________________________
Routing # (9 digits): __ __ __ __ __ __ __ __ __
Account # (16 digits):
Account #:______________________________________
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiration Date:__ __ ∕__ __
Bank account holder or card holder signature:_____________________________________________________ Understanding those numbers at the bottom of your check 1. Your Routing Number is on the left and between symbols that look like “I”. It„s a 9-digit number. 2. Your bank account number may be up to 17 digits in length and is between the Routing number and the check number. 3. Your check number may be encoded on this line. Do not include this number.
If using a checking account, remember to attach a blank check marked as VOID All other states 277 mid-term cc (Rev. 05/2012)
Save time and money! Make your payments electronically. No more hand written checks, no more late fees. Direct debit your account with an electronic funds transfer (EFT)! To apply, follow these easy steps: 1. Complete this form with your name, policy number, bank information and signature. 2. Enclose a blank check from your current checking account and mark this check “VOID” or provide our savings account or credit card information. 3. Mail to the address indicated above of fax to 1-800-682-0817. 4. PLEASE, do not return the form with your payment.
Direct Debit Authorization Agreement In this Agreement, the term “Company” shall mean Bristol West Insurance Company (in AL, AR, CO, FL, GA, ID, IA, IL, IN, KS, KY, ME, MI, MO, MT, ND, NE, NH, OK, PA, SC, SD, UT, VA and WI), Bristol West Casualty Insurance Company (in OH, MN, VA and WY), Bristol West Preferred Insurance Company (in MI), Coast National Insurance Company (in AZ, CA, GA, MS, NV, OR, PA, TN and WA), or Security National Insurance Company (in FL), Home State County Mutual Insurance Company (in TX) or Bristol West Specialty Insurance Company (in TX). Please refer to your Declarations page to determine which entity pertains to you. By signing below, I hereby agree to the terms and conditions of this authorization agreement as follows: As the Named Insured, I hereby authorize the Company to electronically deduct monthly installments for payment of my insurance policy premiums, subsequent renewal down payment and monthly installments, and to initiate credit entries in the event of erroneous charges. I hereby authorize the Financial Institution indicated below to accept and post these transactions to my account, shown below.
This authorization will remain in effect until I provide written notice to the Company of its termination. I understand that, in the event I decide to terminate this payment method, I must advise the Company at least 3 business days prior to the installment due date. In the event that I do terminate it, I understand that I continue to be obligated to make the current payment due as outlined on the payment schedule, and my bill plan and premium may change, requiring a larger down payment and different installment payments.
I authorize the Company to adjust said transactions to reflect any premium changes and policy renewals. The Company agrees to notify me, at least 10 days in advance, in the event that the electronic transaction will be greater than the previous electronic transaction.
In the event that this enrollment occurs after the inception of the policy, we will debit your account the amount reflected on your current invoice, as long as we receive the authorization form at least 3 business days prior to the current due date.
In the event that my Financial Institution or account number changes, I acknowledge that 3 business days advance notice must be given to the Company before the changes take effect. I understand that I will be receiving a payment schedule shortly with the due dates, amounts of future withdrawals, and applicable fees. Upon receipt, I will retain the payment schedule for future reference since the Company will not send out monthly notifications.
I understand and agree that an installment fee will be charged and deducted with each monthly installment payment. I further understand that if my financial institution does not honor any payment, an NSF fee will be assessed to the balance due on my policy. For the specific amount of each fee, please contact your producer or call the Company at 1-888-888-0080. In addition, these fees will be reflected on the payment schedule that will be sent to you after the Company processes this request.
To ensure accuracy, if using a checking account, please attach a sample check and mark it as VOID. Customers of credit unions should verify their account numbers as some credit unions use different account numbers than the numbers printed on checks.
Required information for all payment types, please print clearly: Insured Name:_____________________________________
Date: _____________________________________
Policy Number: ____________________________________
Phone #: __________________________________
Complete the following for checking and savings:
Complete the following for credit/debit card:
Select account type ( ) Checking or ( ) Savings
Select account type: ( ) MC ( ) Visa ( ) Discover
Bank Name:_____________________________________ Name on Account: _______________________________
Name on card: __________________________________
Routing # (9 digits): __ __ __ __ __ __ __ __ __
Account # (16 digits):
Account #:______________________________________
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiration Date:__ __ ∕__ __
Bank account holder or card holder signature:_____________________________________________________ Understanding those numbers at the bottom of your check 1. Your Routing Number is on the left and between symbols that look like “I”. It„s a 9-digit number. 2. Your bank account number may be up to 17 digits in length and is between the Routing number and the check number. 3. Your check number may be encoded on this line. Do not include this number.
If using a checking account, remember to attach a blank check marked as VOID All other states 277 mid-term cc (Rev. 05/2012)
